Removing user fees in the health sector: a review of policy processes in six sub-Saharan African countries

Abstract

In recent years, governments of several low-income countries have taken decisive action by removing fully or partially user fees in the health sector. In this study, we review recent reforms in six sub-Saharan African countries: Burkina Faso, Burundi, Ghana, Liberia, Senegal and Uganda. The review describes the processes and strategies through which user fee removal reforms have been implemented and tries to assess them by referring to a good practice hypotheses framework. The analysis shows that African leaders are willing to take strong action to remove financial barriers met by vulnerable groups, especially pregnant women and children. However, due to a lack of consultation and the often unexpected timing of the decision taken by the political authorities, there was insufficient preparation for user fee removal in several countries. This lack of preparation resulted in poor design of the reform and weaknesses in the processes of policy formulation and implementation. Our assessment is that there is now a window of opportunity in many African countries for policy action to address barriers to accessing health care. Mobilizing sufficient financial resources and obtaining long-term commitment are obviously crucial requirements, but design details, the formulation process and implementation plan also need careful thought. We contend that national policy-makers and international agencies could better collaborate in this respect.

Trends in caesarean delivery by country and wealth quintile: cross-sectional surveys in southern Asia and sub-Saharan Africa

“…25,26 The cost of emergency caesarean sections can be catastrophic for households. 25,26 Although user fee exemptions have been one of the key strategies to increase access to delivery care in subSaharan Africa, 27 their impact on caesarean delivery rates has yet to be rigorously evaluated. While such fee exemptions may have contributed to the rises seen in caesarean delivery rates in countries such as Ghana and Senegal, 28,29 such rises cannot be categorically attributed to the exemptions.…”

Removing the User Fees for the Under-Fives' Simple Malaria Treatment in Cameroon: Effect on the Health Services Utilization

“…Messen et al identify a compensation approach based on inputs in Liberia, outputs in Ghana and Burkina Faso, and a mixed approach in Senegal [32]. Not satisfied with the approach based on inputs in the past, Burkina Faso decided that health facilities should be compensated according to their activity (output-based payment).…”

Nurses’ perceptions of universal health coverage and its implications for the Kenyan health sector

“…Furthermore, nurses alluded to a sense of injustice, not only at having not been consulted about the policy change, but also from being told that their work load will increase significantly without increasing their pay. Unfortunately, this finding too is supported by work in six African countries that illustrated nurses were never consulted during policy formulation on fee removal policies (Meessen et al 2011). Additional strain placed on an already overloaded and thinly stretched workforce contributes to the widespread belief that nurses are not valued in the health system, as seen in South Africa (Walker and Gilson 2004;Joyner et al 2014).…”